1. Developments in colorectal surgery
Mr SV Gurjar
Consultant Colorectal Surgeon & Clinical Director
11th October 2017

2. In the news….!

3. What will I be talking about?
The L&D colorectal surgeons and team – an overview.
How has colorectal surgery developed over the decades…
What do we offer?
What the future holds?

4. Colorectal Surgeons
Currently 6 surgeons in post; an extra surgeon is starting in January with a colorectal and paediatric interest
Part of a 12 consultant on call service to offer acute and elective general and colorectal surgery to local population
Weekday dual consultant rota
Aim for colorectal surgeons to do the major colorectal work (eg resections, coloproctology and stoma formation)

5. Colorectal surgery has evolved…

7. From big incisions to small ones…!

8. Origins of keyhole surgery
Urology
Gynaecology – to look at ovaries and tubes
Laparoscopic cholecystectomy (gall bladder extraction)
Prof Mühe, Böblingen, Germany
12th September 1985
First colectomy (colon removal) was in the 1990s
Initial fears about oncological safety: was this as safe a way to remove a bowel cancer as the old fashioned approach?

9. The age of colorectal trials
To prove the clinical effectiveness of keyhole techniques
Multi-centre
Worldwide (UK, USA, Europe & Australasia) eg
COST (Clinical Outcomes of Surgical Therapy)
COLOR (Colon carcinoma or Open resection)
CLASICC (Conventional vs Lap-assisted surgery in colon cancer)
All showed equivalence in terms of overall survival, disease-free survival and rates of local recurrence

10. Biggest benefits Length of stay is significantly reduced
in conjunction with enhanced recovery principles
Experience of pain
Earlier return of bowel function
Immune benefits
body immune response is lessened and thereby recovery is quicker
Smaller scars – patients prefer!

11. NICE Technology Guidance TA105 (issued 2006)

12. What do we offer at L&D
5 surgeons are competent in laparoscopic (keyhole) techniques
1 surgeon is focused on the complex cases that need an open approach
Multi-disciplinary discussion of all cases
involves all specialties in decision-making process
Team-working approach
shared overview on weekly basis
joint consultant operating for the difficult cases

13. Multi-disciplinary approach
Pre-operative counselling from
CNS team
Stoma team
Point of contact
Named nurse who is available during the patient journey for any issues/concerns
Longer term nursing follow-up
Five year colorectal nurse-led surveillance
Stoma care in the community
Ease of access and return to main clinic if need arises

14. SILS – Single incision laparoscopic surgery
Means that all operating is done through one larger port usually at/around umbilicus
Technically more challenging and time-consuming

15. SILS – Single incision laparoscopic surgery

16. TAMIS

17. taTME

18. taTME – transanal TME Trans—anal approach to excision of rectum
Newest technique, currently undergoing evaluation
Will allow two teams to operate from top and from bottom, thereby shortening operative time
Oncological safety
Suited for elderly patients needing shorter operative time and anaesthesia, or male pelvis with low rectal tumour

19. Role of Enhanced Recovery
Combination of evidence-based strategies which synergistically help to expedite recovery after surgery
Fast-track surgery
Multi-modal optimisation
Irene will discuss separately

20. The future: is it robotic??
First performed in 2001: added degrees of freedom which can improve access in the difficult pelvis
Based on da Vinci system (Intuitive Surgical)
Concept of robotic total mesorectal excision for rectal cancer first reported in 2006
Better TMEs and nerve preservation?
Jury is out – role is evolving. Early results from ROLARR (Robotic vs Laparoscopic resection of rectal cancer) show no real advantage. Its time may come…

21. Da Vinci robot system

22. In conclusion: Colorectal surgery has come a LONG way
Surgery is no good in isolation
Multi-disciplinary approach is essential
Involve the patient & embrace innovation

23. THANKS